Below is a list of our available forms that you can download and print. Click the arrow to download printable forms.

download-arrow Medical Records Request

download-arrow Letter of Support

download-arrow Patient Contract

download-arrow Uninsured Application Checklist

download-arrow Patient Portal Authorization

School Forms

download-arrow School Entrance Health Form

download-arrow School Athletic Participation/Physical Examination Form

Medicare Wellness Forms

download-arrow Adult Questionnaire

download-arrow Patient Health Questionnaire

download-arrow Medicare Annual Wellness Assessment

download-arrow Fall Risk Assessment

New Patients Adult – 14 yrs and older

download-arrow Patient Information

download-arrow Adult Questionnaire

download-arrow Patient Rights and Responsibilities

download-arrow Medical Records Request

download-arrow Patient Contract

download-arrow Patient Portal Authorization

download-arrow Notice of Information Practices

download-arrow HIV Consent

download-arrow Uninsured Application (English)

download-arrow Uninsured Application (Spanish)

download-arrow Authorization to disclose health information

New Patients Pediatric 0-13 yrs old

download-arrow Patient Information

download-arrow Pediatric Questionnaire

download-arrow Patient Rights and Responsibilities

download-arrow Medical Records Request

download-arrow Patient Contract

download-arrow Patient Portal Authorization

download-arrow Notice of Information Practices

download-arrow HIV Consent

download-arrow Uninsured Application (English)

download-arrow Uninsured Application (Spanish)

download-arrow Authorization to disclose health information

Don’t see a form you need? Let us know by calling our office at 540-785-8500.

We Now Have the COVID-19 Vaccine!

Where: Fredericksburg Christian Health Center

When:  Tuesdays 8am to 10am and Thursdays 2pm to 4pm

Who: Ages 18 and over

How to Sign Up:

Call 540-785-8500 or log onto MyChart to make an appointment

 

Ahora tenemos la ¡Vacuna para el COVID-19!

Dónde:   Fredericksburg Christian Health Center

Cuándo: Martes de 8 am a 10 am y Jueves de 2pm a 4pm

Quién:    Mayores de 18 años

Cómo registrarse:

Llame 540-785-8500 o inicie sesión MyChart para hacer una cita